JMIR Publications

ABSTRACT

Background:

Effective clinical decision support systems (CDSS) require accurate translation of practice recommendations into machine readable artefacts. Developing code sets that represent clinical concepts are an important step in this process. Many clinical coding systems are currently used by electronic health records to represent clinical concepts, and it is unclear whether all of these systems are capable of efficiently representing the clinical concepts required to execute CDSS artefacts.

Objective:

The aim of this study is to evaluate which clinical coding systems are capable of efficiently representing the clinical concepts required to execute CDSS artefacts.

Methods:

Two methods were used to evaluate a set of clinical coding systems. In a theoretical approach, we extracted all the clinical concepts from three preventive care recommendations and constructed a series of code sets containing codes from a single clinical coding system. In a practical approach using data from a real-world setting, we studied the content of 1890 code sets used in an internationally available CDSS and compared the usage of various clinical coding systems.

Results:

SNOMED CT and ICD-10 proved to be the most accurate clinical coding system for most concepts in our theoretical evaluation. In our practical evaluation, we found that ICD-10 was most often used to construct code sets. Some coding systems were very accurate in representing specific types of clinical concepts such as LOINC for investigation results and ATC for drugs.

Conclusions:

No single coding system seems to fulfill all the needs for representing clinical concepts for CDSS. Comprehensiveness of the coding systems seems to be offset by complexity and forms a barrier to its usability for code set construction. Clinical vocabularies mapped to multiple clinical coding systems could facilitate clinical code set construction. Clinical Trial: N/A